Anticipating open enrollment season for coverage in 2019, the Centers for Medicare and Medicaid Services (CMS) released coverage and premium information that will factor into consumer decisions about Medicare and individual commercial plans offered through exchanges. Enrollment and premium trends also inform regulatory and broader policy decisions at both federal and state levels.
Centers for Medicare and Medicaid Services
Court Decision on Overpayment Rule Leaves Uncertain Future for Medicare Payment Methodology and Pending Justice Department Lawsuits
By Bruce Arnold on
Posted in ACA
A federal court decision to vacate regulations concerning “overpayments” to Medicare Advantage plans has left open questions about the way the government pays the insurers and pending cases brought by the U.S. Department of Justice.
Performance Report: “Pathways” Rules Help CMS Advance Two-Sided Risk Sharing
By Bruce Arnold on
Posted in Accountable Care Organizations
This is the second article in our series on the new “Pathways” rules for Accountable Care Organizations. Our first article in the series can be found here.
The Centers for Medicare and Medicaid Services (CMS) released a report on August 27, 2018, showing Next Generation accountable care organizations (ACOs) produced net savings of $62 million in 2016 while maintaining quality of care. CMS Administrator Seema Verma pointed to the savings as evidence that ACOs taking two-sided risk succeed, according to a CMS press release.
Nursing Facilities Need To Update Their Admission Agreements
By Emily Solum on
Posted in Post-Acute Care & Nursing Facilities
By now, everyone operating a skilled nursing facility knows about CMS’ 2016 overhaul of the Requirements for Participation for Long-Term Care Facilities (“RoPs”). The final rule amending the RoPs was published on October 4, 2016. See 81 Fed. Reg. 68688 (Oct. 4, 2016). Many of the changes made by CMS do not impose new requirements on facilities, but instead clarify existing requirements. While CMS has been implementing the various changes in three phases over a three-year period, facilities should by now have implemented or taken steps to implement all of the new requirements.
We have reviewed the new RoPs and guidance documents issued by CMS to determine how the changes impact nursing facility admission agreements. There were changes or clarifications to a number of subjects that impact such agreements, including: resident discharge requirements, resident representative requirements, selection of attending physicians and other health care providers, room transfer and roommate requirements, visitation rights, facility liability for resident property, bed hold policies, etcetera.
CMS Proposed Rule Would Redesign Medicare Shared Savings Program
By Hal Katz & Julia Zaft on
Posted in Accountable Care Organizations
In an August 9, 2018 proposed rule, the Centers for Medicare & Medicaid Services (CMS) seeks to redirect the Medicare Shared Savings Program (MSSP) on so-called “Pathways to Success.”
Telehealth Trend: Are Your Claims Reimbursable Under Medicare?
By Hal Katz & Loreli Wright on
Posted in Reimbursement, Telehealth
With the global telehealth market projected to more than quadruple in value over the next five years, even slow-moving government payors have responded to the pressure to expand reimbursement options for telemedicine services. But reimbursement woes continue to top the list of concerns voiced by providers, and the U.S. Department of Health and Human Services, Office of Inspector General (“OIG”) is keeping a watchful eye on reimbursement-related growing pains. On April 30, 2018, OIG released a report that identifies the impact of some of these growing pains on Medicare claims payments.
Lookback Periods for Medicaid Overpayments
By Renee Zerbonia on
The 60-day repayment rule was implemented by the Centers for Medicare and Medicaid Services (CMS) effective March 14, 2016 to clarify Medicare providers’ obligations to investigate, report, and refund identified overpayments under the Affordable Care Act. The rule specifically details what it means to “identify” an overpayment and explains how to report and return identified overpayments to CMS.1 The rule also states that an overpayment must be reported and returned if it is identified within six years of the date it was received. This time period is generally referred to as the “lookback” period.
Revised SRDP Process Begins June 1
By Julie Sullivan on
Posted in Compliance
Beginning on June 1, 2017, health care providers of services and suppliers must submit all information necessary for the Centers for Medicare and Medicaid Services (“CMS”) to analyze actual or potential violations of the federal physician self-referral law (the “Stark Law”) using approved forms designed to streamline the CMS Voluntary Self-Referral Disclosure Protocol (the “SRDP”). If you are currently working on a self-disclosure filing for CMS, you must convert that disclosure to this new format or risk CMS rejecting the disclosure in its entirety. The new forms, contained within Form CMS-10328 available here, must be used for all voluntary Stark Law self-disclosures submitted on or after June 1, 2017, except disclosures by physician-owned hospitals and rural providers regarding a failure to disclose physician ownership on the provider’s website or in any public advertisement.[1]